Friday, April 23, 2010

There was a fascinating plenary session about treatment of thyroid cancer today. And therein lies one of my frustrations working outside of an academic medical center, and in the real world. And in some ways, I feel helpless about it.

We know that for the most part, patients with differentiated thyroid cancer have excellent prognosis. There is also ample published data from my alma mater that adequate surgery is virtually curative in stage 1 and 2 patients; there is virtually no survival benefit of additional radioactive iodine ablation. Hence, the bias I picked up from there is, low risk patients do not usually need ablation. However, the sonographers there are amongst the best in the world, and if there is disease in a node, they call it. And the surgeons do a good job with the surgery. I131 should not be used as a technique to 'clean up' tumor burden left behind by the surgeon because of inadequate pre-op evaluation. I know, this might be a somewhat debated topic, but the 20-year survival data they published is hard to argue against.

Problem is, outside of large centers like that, you realize you have no control over what someone else does before they consult you. And when the endocrinologist is consulted only AFTER surgery, and when they didn't even look at the lymph nodes before and during surgery, you realize sometimes your hands are tied. And if the radiologist has the blatant honesty to say they don't trust their techs to look at the the cervical nodes, even if you could have, how much weight would you put on cervical sonography? (admittedly I'm not sure if they were also motivated financially to suggest a CT scan for all my cancer patients rather than the cheaper ultrasound). Are you really going to take the risk of not ablating that patient?

In that sense, I miss working in an institution where everyone communicates with each other, and are all in agreement of the best plan of care. In the meantime, I guess I can only do my best and hope I'm guiding my patients in the right direction.


Anonymous JN said...

I'm a training radiologist in spore, and i am disturbed about your comment about radiologists recommending a ct scan over an ultrasound for financial gains.

When we question the wisdom of doing certain scans which we feel will not be beneficial for the ptient, we are termed 'slackers'. But when we recommend an imaging modality that is superior, but obviously more expensive, our motives are questioned. Of course an ultrasound scan of the cervical region is cheaper and faster, but it is also operator dependant, as are all ultrasound scans. Unless you have had prior experiences with the said-radiologist which would cause you to question his/her motives, i think, as colleagues, it is only polite to give that person the benefit of the doubt and not imply that radiologists are driven by monetary gains on a very public blog with a substantial readership.

1:52 AM  
Blogger vagus said...

JN, thanks for stopping by.
Your point about operator variables about the ultrasound is well taken, and yes in that sense the CT may be better...
However it would be naive of me to not be cautious for the patient. Medicine has become too much of a business methinks, this plagues all specialties. So, when I see an endo who keeps doing biopsies of stable nodules yearly, or surgeons who are gungho about sending asymptomatic benign stable nodules to surgery, or radiologists who keep doing annual I131 thyrogen stimulated whole body scans in a low-risk thyroid cancer pt with negative markers, you do have that question pop up in your head (so I wasn't directing this to only radiologists, and certain did not mean all radiologists are greedy. I wouldn't dare; one of my good friends from S'pore is a radiologist and we just had dinner 2 days ago!).
In this situation though I am left in a dilemma because I simply see so many thyroid cancer patients and for a vast majority I know it's going to be very low-risk. And so, with the same reservations I have about the I131 therapy, I do wonder if ALL these patients should be getting a CT (or heaven forbid, I've been suggested by one particular radiologist to use the PET!!) for routine nodal screening. Or if a group isn't comfortable doing nodal ultrasounds, would it be more cost effective for the patient to just use a different radiology group that just have more experience with it?
Because from a therapy standpoint, having a surgeon say "I'm not very good in doing this kind of procedure, so let's do something more aggressive instead" doesn't sound right, does it? We'd just find a surgeon who has more experience in the latter procedure!

6:03 AM  
Anonymous JN said...

I certainly applaud your vigilance when it comes to having your patients' best interest at heart, and if I came off a little strong, I do apologise. I have been following your blog for a few years now, and have always admired your dedication and especially your empathy and your compassion for your patients.

You're right - medicine HAS become too much of a business. The reputation of the medical profession has suffered greatly because of that. And you are right, as radiologists, we have an obligation to provide the best possible service appropriate to the patient. Perhaps that particular radiologist was just being brutally honest about the deficiencies of his group :)

But certainly, no PET scan!!! :P

7:56 AM  
Blogger pavlova said...

Your point about medicine becoming a business, can it be happening more prevalently in the US because of the state of healthcare?
As most of us know, the insurance and privatisation of healthcare is a strong force in the US while other "socialist" countries like UK, which doctors are paid on a fixed wage and when the healthcare is free, one would have a better opportunity to establish a treatment plan that is based on the patient's best interest rather than the dollar signs?

4:01 PM  

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